Monthly Archives: October 2018

Standing in the shadow of addiction

By Lindsey Phillips October 30, 2018

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Theresa Eschmann, a licensed professional counselor (LPC) and addiction family specialist in private practice in St. Louis, experienced firsthand the power of denial in adult children of parents with alcohol use disorders. All her life, Eschmann had witnessed her mother struggle with this disorder, yet upon finding her mother dead with a bottle of alcohol in her hand, Eschmann’s first response was denial. She couldn’t believe that her mother’s alcohol use disorder had caused her death, initially insisting that someone must have poisoned her.

“I … took a chemical dependency proficiency certification to try to get some understanding of what killed her because it couldn’t have just been alcohol,” Eschmann says, explaining her thinking at the time. “Alcohol made you sick. It made you have delirium tremens. It made you see things. But it couldn’t have killed you.”

Denial is often a strong coping mechanism for adult children of parents with alcohol use disorders, says Lisa Kruger, an LPC and psychotherapist and the owner of Stepping Stone Psychotherapy in the Washington, D.C., metro area. “They have to deny any feelings of sadness or anger that they might have in order to survive,” she says.

This denial extends to adult children’s own potential struggles with substance use disorders. Keith Klostermann, an assistant professor in the Department of Counseling and Clinical Psychology and the director of clinical training for the marriage and family therapy program at Medaille College, had a female client whose father chronically abused alcohol, and her own drinking often led to fights with her boyfriend. One of these drunken fights resulted in her breaking her foot. Even so, she maintained a permissive attitude toward drinking and brushed it off as a recreational activity.

The client was firmly in denial and not yet ready to address either her experience of growing up around substance abuse issues or her own drinking habits, says Klostermann, a licensed marriage and family therapist and licensed mental health counselor who maintains an active practice in New York. Counselors may be eager to push clients to explore these issues, but Klostermann warns that discussing the implications of this childhood experience before clients are ready is a recipe for disaster. Taking that approach may lead to problems establishing a therapeutic alliance or cause clients to end counseling prematurely, he explains. Instead, he advises, counselors can help clients connect the dots and arrive at an understanding that their behavior makes sense based on their experiences growing up.

Asking the right questions

Being an adult child of a parent with a substance use disorder is not uncommon. According to the National Association for Children of Addiction, 1 in 4 children in the United States (or approximately 18.25 million children) live in a family with a parent who is addicted to drugs or alcohol. Yet, Eschmann, a certified master addiction counselor and a member of the American Counseling Association, says it’s her sense that asking whether clients grew up in homes where addiction was present is often skipped over in clinical assessments.

In addition, because these individuals have frequently learned to minimize, discount or deny the implications of growing up in a home with substance abuse, they aren’t particularly likely to seek counseling for those issues.

Being a child of a parent who abused substances “may be the elephant in the room, but that may not be what brings them in. They may not recognize it,” says Klostermann, an ACA member. “The stuff that happens to us when we were younger, a lot of times we carry with us, [but] we don’t even realize why we do the stuff we do. We just sort of do it out of inertia.”

Klostermann and Kruger say that many of their clients present with relationship problems, anxiety, stress, depression and substance use. Often, the counselors note, these issues result from growing up with a parent who had a substance use disorder.

The environment of walking on eggshells around a parent who is under the influence of a substance creates and breeds anxiety for the child, Klostermann explains. When the child becomes an adult and engages in stressful situations in college (e.g., exams) or at work (e.g., deadlines), the person’s anxiety can snowball, he adds. Likewise, they may struggle with adversity and withdraw socially because they find it difficult to navigate relationships. This isolation can lead to depression, which is a real challenge, Klostermann says.

Counselors can look for possible warning signs that their adult clients were exposed to substance abuse issues in the home as children, Klostermann says. For instance, clients might engage in avoidant strategies (e.g., using alcohol as a way to cope with stress) or have a permissive attitude about substance use (e.g., “I don’t drink much. I only have a 12-pack a day.”).

Kruger, an ACA member who specializes in the areas of depression, anxiety, posttraumatic stress disorder, trauma and addiction, had a male client who came to see her for help with relationship issues and high anxiety. In his intake paperwork, the client wrote that he drank nightly, so she asked him how many drinks he had in a week. “It was 50 to 60 a week,” he replied, “but now it’s only 20 or 30.” This response was a big red flag, yet he didn’t realize that his drinking was a problem, she says.

To help clients recognize unhealthy behaviors, Kruger often uses motivational interviewing techniques. For example, with this client, a counselor might ask, “How is drinking 20 or 30 drinks a week working out for you?”

If counselors see potential warning signs, Klostermann advises asking questions about current substance use patterns, previous substance use, parental substance use and family attitudes around drinking. For example, counselors might ask the following questions: What was it like growing up in your home? What does drinking a lot or having a good time mean to you? What does that look like? What are the holidays and celebrations like in your family? What is a typical family dinner or birthday party like?

“Substance use is built around so many family functions and gatherings and celebrations,” Klostermann says. So, if a client comments, “My parents liked to party,” counselors could follow up by asking the client to explain what that means and what the implications are for the client’s life (e.g., increased violence after a parent drank, embarrassment when a parent became intoxicated at a social event). Klostermann explains that these types of questions help clinicians gain a better understanding of not just the acute nature of growing up in an environment with substance abuse but also the context of it — for instance, whether parental drug use led to a more permissive attitude at home or whether the child adopted unhealthy coping strategies.

In addition, adult children often find it easier to talk about others rather than themselves, Klostermann says. By asking these types of nonjudgmental questions (e.g., “Did drinking like that seem to work out for your mom?”), counselors can help clients create insight and awareness by changing the frame of reference, he explains. This technique helps clients gain an understanding about not only the severity of their parents’ alcohol or substance use but also the emotional implications of that behavior, he adds.

After counselors establish that awareness, Klostermann says, they can connect it to the client’s present situation (e.g., “Does drinking affect your relationships or grades?”). He suggests that counselors could also try to educate clients by saying something along the following lines: “Given what you described about your [parent’s] history, it’s not uncommon for people that grow up in these homes to sometimes exhibit certain behaviors. Sounds like that might be happening for you.”

Counselors are “planting the seed [and] leaving the door open but also helping [clients] to connect the dots and understand this is what’s going on and here’s why,” he explains.

In addition to asking about clients’ personal and family substance use histories, Kruger often focuses her questions on clients’ relationships with their parents. These questions can help bring out emotions such as shame, guilt or anxiety that stem from being a child of a parent with a substance use disorder, she says.

Emotional and attachment wounds

“Adult children of alcoholics … have difficulty identifying and expressing emotions,” Kruger explains, “because when they were kids, they had to set aside their own emotions — maybe they had to care for their parents. … They didn’t understand what their emotions were because what they saw in their parents’ relationship was inconsistent presentation or organization of emotions between them and maybe even between the parent and child too.”

To help clients who are having difficulty expressing their emotions, Kruger provides a sheet that shows 50 visual representations of emotions and asks clients to name the emotions that describe how they are feeling. She says this activity, which she refers to as an “emotional cheat sheet,” is “a good springboard … for clients who really don’t have the language [for their emotions].”

Kruger and Eschmann find that codependency is another common issue for adult children of parents with alcohol use disorders. Because these adult children grow up being sensitive to the needs of their parents — even to the point of ignoring their own needs — they often engage in approval seeking, which leads to codependency, Kruger explains. This need for approval and to avoid conflict can result in these individuals seeking acceptance from others who do not treat them well, which causes lower self-esteem, she says.

Often, clients who are codependent will assume they are OK because they are not the ones causing problems, Eschmann observes. She questions clients on codependent behavior by asking about their controlling behaviors, approval-seeking behaviors, anxiety, and distortion around intimacy and separation.

For Kruger, it all comes back to attachment — how bonds are created and broken. Parents who struggle with alcohol use disorders are typically inconsistent in their parenting and in their show of emotion toward their children. As she points out, this can create attachment wounds and be stressful for children growing up under these circumstances. Children may be doubly affected because they still depend on parents for care and for getting many of their emotional needs met. At the same time, these children often aren’t in a position to fight or to flee elsewhere, she adds.

Counselors can help adult clients gain awareness of how their current relationship patterns are affected by their childhood experiences, Kruger says. One technique she finds helpful involves taking the client’s experiences and imagining how those experiences would be perceived on The Brady Bunch. As a member of The Brady Bunch family, Kruger explains, the client would notice instantly if a partner or spouse were abusive because of the contrast with the sitcom family. However, growing up in a stressful environment with one or both parents suffering from an alcohol use disorder tends to distort a person’s perceptions of what is “normal” or acceptable.

For example, having a parent who drank and was inconsistently present when the client was a child would affect the client’s ability to evaluate his or her current relationships. If the client has a partner who sometimes withholds affection or emotion, is manipulative and comes around only when he or she wants something, the client won’t necessarily notice any red flags because those are the circumstances and relationship patterns the client knows from growing up, Kruger explains.

Kruger also gives short attachment assessments and finds that these clients often present with anxious attachments. “In relationships, [they cater] to the other person because that attachment anxiety comes up and that need for approval keeps them in relationships” — including bad ones, she says.

To help clients see the connection between their view of themselves and their relationships with others, Kruger will have clients write out how they view themselves, how they view other people and how they view the world. Then, they will discuss how these views are created, how clients are perpetuating these views and how they would like to see themselves in relationships.

The exercise is particularly helpful for clients who find themselves in toxic relationships, Kruger adds. “It’s really rare [for] somebody in a toxic relationship [who is] being manipulated to say, ‘I see myself in high regard, and I think I’m great.’ It’s usually the opposite,” she says.

Making meaning of conflicted feelings

Another crucial part of adult children’s recovery is sorting through their conflicted feelings of love, disappointment, anger and shame. In fact, both Eschmann and Kruger find that shame and guilt are common presenting issues.

Children often feel that a parent’s situation is their fault, and they find it difficult to process these multilayered emotions, Kruger notes. They simultaneously feel disappointment in and love for their parent. For adult children, processing and making sense of these feelings is a substantial part of recovery, she explains. Counselors should acknowledge that shame piece and how clients have “put that burden on themselves and carried that burden with them throughout adulthood,” Kruger advises. 

“Shames translates to I am bad,” Kruger points out. “Even if [clients] don’t present it on the outside, they’re usually coming in with some pretty damaged self-esteem and are already judging themselves.” In part for that reason, she emphasizes the importance of creating a nonjudgmental atmosphere in counseling.

When self-esteem, thoughts and feelings are involved, Kruger uses cognitive behavior therapy techniques. She says she has experienced a good deal of success with an exercise that blends cognitive restructuring and emotion identification. In the exercise, clients look at a triggering event and then identify their negative self-talk and automatic thought, the feeling that this thought creates, evidence to strengthen this thought, evidence against this thought and a new thought that they can believe.

The exercise allows clients to recognize their negative self-talk and its consequences and enables them to reconfigure these self-demeaning thoughts in a way that is believable to them, Kruger explains. For example, clients might think that they are “bad” and list all of the evidence they have for that thought. Next, they could counter that thought with the fact that they recently got a raise at work. Finally, they could create a new thought that sometimes they do good things, Kruger says.

“These clients need validation,” Eschmann emphasizes. “They didn’t get it growing up.” Instead, she explains, the parent who was abusing alcohol or other substances has often discounted the adult child’s feelings and experiences.

Klostermann also stresses the importance of normalizing these clients’ emotions and experiences. These clients may not realize — or, in some cases, perhaps don’t want to realize — the impact on them of their parents’ drug or alcohol use, he says. He notes how difficult it can be for clients to verbalize that their parents had or have a drinking problem, especially if they maintain a glorified version of their parents. For this reason, counselors need to help clients understand that it is possible for them to love their parents while still recognizing that their parents made mistakes.

Kathleen Brown-Rice, department chair and associate professor in the Department of Counselor Education at Sam Houston State University, agrees. Counselors must keep in mind that the family member is someone whom the client still loves and cares about, she says. Counselors can give clients the “space to say that you can love somebody and also be disappointed by their behaviors. You can love someone, and they can love you, and they can still hurt you,” she says. “[It’s] helpful for clients to understand that it’s more complicated than just [their parents are] bad or they don’t love [them].”

Eschmann helps clients focus on unresolved grief, which is common for adult children who grew up with parental substance abuse. Adult children are often hesitant to admit that their mom left them alone all night with a stranger or that their father came home drunk and had violent arguments with their mother, Eschmann says. They might not want to admit that these past events are why they get triggered today during certain situations.

“[Clients] have to accuse before [they] can excuse,” Eschmann asserts. “They have to go back and [ask], ‘What happened to me?’ This isn’t about [the parents] anymore. It’s about [the client].” If clients become more aware of what happened to them and what kind of environment they lived in that made them fearful and anxious today, then they can start healing, she adds. 

Mindful resilience 

Adult children who grew up in the same environment with substance abuse can respond very differently. One person may be angry, whereas another may be empathetic, and still another may end up also struggling with a substance use disorder. This raises the question of why some adult children of parents with alcohol use disorders are more resilient than others.

Resilience is “critical in terms of shaping kids’ development as they transcend into adulthood in terms of the choices that they make and the way that they deal with stress and conflict,” Klostermann points out. Based on his clinical experience, Klostermann suggests that having other healthy outlets (e.g., extracurricular activities such as sports, positive role models such as grandparents) and an ability to contextualize what is happening help to foster resilience.

Brown-Rice, an LPC and a member of ACA, acknowledges that there is more than simple genetics at play with resiliency. “Resiliency is not a moral characteristic. It’s a function of our brain,” she says. It’s “how our brain controls for those genetics … how that resiliency comes in and how we support that.”

Recently, she, along with Gina Forster (a lecturer in the Department of Anatomy at the University of Otago) and several other colleagues, conducted a study funded partly by a grant from the Center for Brain and Behavior Research at the University of South Dakota on college students who had similar experiences of being adult children of parents with substance use disorders. The participants identified as either engaging in risky substance use (the vulnerable group) or not engaging in risky substance use (the resilient group).

“Overall, their experience being raised by a parent who met the criteria for having a substance use disorder appeared similar,” says Brown-Rice, who presented the findings at the ACA 2017 Conference in San Francisco. However, “vulnerable individuals had lower scholastic performance … [and] reported poor overall psychological, physical and social health and more polysubstance use.”

The study also revealed another difference: The vulnerable group had a short allele of the serotonin transporter gene, which meant they were more likely to react to stressful events. “[This group] had a reduced uptake of their serotonin, which can increase depression and stressful life events,” explains Brown-Rice, associate editor of the Journal of Addictions & Offender Counseling.

Brown-Rice and the other researchers also measured brain activity while the participants viewed positive images (e.g., a cuddly bear), negative images (e.g., a crying baby) and neutral images (e.g., a chair). They found that the vulnerable group had altered brain activity when processing negative images. This group recognized the negative image but refused to store it, Brown-Rice explains.

Brown-Rice hypothesizes that this refusal to store negative images is an important factor in resiliency levels. To illustrate, imagine that you are walking outside and see a stick. Initially, your brain may think that the stick is a snake, so you jump back. As Brown-Rice explains, when you first see the stick, the amygdala activates and warns you because it looks like something that the brain remembers could hurt you. But after taking a closer look (i.e., storing the image), you realize it is just a stick, so you relax.

Resiliency depends on our ability to realize that the stick is not a snake. Some people, however, may be more likely because of brain functioning or genetic variations to see the stick and just react by running, Brown-Rice says. Thus, counselors can help certain clients by nurturing the parts of the brain that activate during stressful situations, she explains.

Brown-Rice incorporates this research into her clinical practice. She tells her clients that they have a resilient part of the brain — the prefrontal cortex — and that in session, they can work on controlling their brain and building their optimism and resiliency. She suggests that counselors use mindfulness techniques, such as guiding clients in breathing exercises and finding a safe place to go when triggered, because mindfulness is effective in calming the amygdala, which activates during stressful events.

Consistency also helps promote clients’ resiliency, Brown-Rice notes. If counselors are inconsistent, she says, that will put clients on edge.

Klostermann agrees. He finds that having a clear agenda helps to create a sense of safety and build rapport with clients. He informs them about his clinical approach and what to expect during the session and tells them there is no assumption on his part that they will schedule another appointment.

Kruger recommends using clients’ resiliency to help strengthen their internal sense of self. After all, she points out, adult children of parents with alcohol use disorders have already developed survival strategies, such as caring for siblings in areas in which the parent was lacking.

Instead of simply telling clients that they have strengths, Kruger uses motivational interviewing, which allows clients to identify and recognize their strengths themselves. For example, rather than telling a client, “You seem to be good at your job,” she might ask, “In what ways are you praised at your job?” This question helps clients reach the conclusion themselves, which builds their internal positive regard.

One more piece of advice for working with adult children of parents with substance use disorders: Counselors shouldn’t be afraid to change their approach if it’s not working. For example, Brown-Rice says, research has shown that people who have a short allele for serotonin may be resistant to cognitive behavior treatment. “If clients are not responding, we have to think maybe we need to change,” she says. “Maybe we need to move. Maybe we need to [incorporate] some of these mindfulness techniques. Maybe we need to do something else.”

Sometimes, it may be the counselor, not the client, who is being resistant, she stresses.

Halting the domino effect

The desire to get treatment for someone with a substance use disorder often overshadows the way that addiction affects the person’s family and others who care about the person. It shouldn’t.

In her educational video on addiction in the family, Claudia Black, an expert in addiction, highlights a child’s drawing of his experience living in a home where substance abuse is present. The child draws images of dominoes and writes, “Alcohol and drugs are like dominoes. They knock down the person, who knocks down everyone, including themselves.” The child’s words illustrate the way that addiction permeates and affects the entire family, not just the person with the substance use disorder.

For the first two years after her mother died from alcohol-related causes, Eschmann found herself crying repeatedly. Her grief and denial led her to learn more about chemical dependency, addiction and adult children of parents with alcohol use disorders. Counselors need to understand that the family has an emotional illness as well, Eschmann emphasizes. This illness is just as progressive as what the person with the substance use disorder is facing, she adds.

Brown-Rice reminds clients that they are not responsible for their substance use issues, but they are responsible for how they respond to these issues. For adult children of parents with substance use disorders, this means learning how their childhood experiences affect their current behaviors and choices.

Adult children of parents with substance use issues often feel isolated. Support groups such as Al-Anon and Adult Children of Alcoholics are helpful because they provide opportunities for people with similar experiences to share their stories and come to the realization that they’re not alone, Kruger says.

Counselors should also help clients understand that their parents’ substance use is not their shame to carry and substance abuse is not a legacy that they have to repeat, Brown-Rice says. Then, clients will realize that choosing a different path doesn’t mean that they are being disrespectful or dishonoring their parents, she explains.

The hope is that this different path will stop the domino effect of addiction, shame, depression and pain.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Generational divisions in the workplace: Where counselors come in

By Bethany Bray October 29, 2018

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More than 1 in 3 American workers are part of the millennial generation, according to the Pew Research Center. This growing contingent of young professionals works alongside supervisors and co-workers who came of age when workplace dynamics were very different. These differences encompass everything from demographics to overall level of reliance on technology.

If left unaddressed, these dynamics can be a recipe for conflict and division, assert Carolyn Greer and Kimberly Key, who have co-presented on the topic of bridging the divisions in the modern workplace at ACA’s annual conference.

“The baton is not passing very well,” says Key, a licensed marriage and family therapist with a private practice in Austin, Texas. “It’s so systemic and vast and complex, with multiple factors that influence this [issue]. … There’s not just one factor.”

Millennials are “digital natives,” accustomed to internet connectivity and the flexibility afforded by the ability to video chat and send email at any time and to anywhere. The need for a 9-to-5 workday in which someone is physically in the office and at a desk can often seem needless or archaic to these younger professionals. Their older co-workers – baby boomers and members of Generation X – however, grew up in a world where the term “work-life balance” was nonexistent and many people stuck with one company or one career for their entire adult life.

“Not only was working from home not feasible a generation ago, it wouldn’t have been allowed. Expectations were very, very different,” says Greer, a retired licensed professional counselor, a longtime member of the American Counseling Association and a past president of the Texas Counseling Association. “That older worker, they set aside family and said, ‘It’s all about work.’ While millennials say, ‘It’s all about family, and work comes second.’ They opt to work from home and take personal time more often. There may be resentment from older co-workers, [who feel] ‘somebody has to hold down the fort!’ There are differences in expectations: What does it mean to go to work?”

Technology aside, modern workplaces look very different than they did a generation ago, in everything from dress code to the benchmarks used for promotion and advancement, notes Greer. At the same time, more and more women are attending college and joining the workforce, and the role of stay-at-home dad is not as unheard of as in decades past.

The Pew Research Center reports that the U.S. labor force is currently a varied mix of generations that even includes a small percentage of post-millennials, or those born after 1996. Baby boomers are slowly retiring, but a healthy share of the American workforce (25 percent in 2017) is still composed of those born during the post-World War II years (1946 to 1964). Roughly one-third of the labor force hails from Generation X, or those born after the baby boom but before the 1980s. Millennials, or those born between 1981 and 1997, have surpassed both generations in recent years to make up the largest percentage of American workers, according to Pew.

The divisions that can arise when generations with different expectations are working side by side is an issue that needs more attention and further discussion within the counseling profession, Key and Greer assert. The duo met through the National Employment Counseling Association, an ACA division in which they are both active. Key also offers training and consulting work on bridging family and work issues.

Key and Greer encourage counselor practitioners to seek professional development in this area, consult with colleagues and get involved in professional counseling organizations such as ACA and NECA. “This is a call to action: Take it to your local professionals, bring it up, talk about it, do research,” Key says.

 

Counselors as bridge builders

Counselors of all specialties – not just career counselors – should be aware of and sensitive to the generational divisions that can arise in today’s workplaces, say Key and Greer. Practitioners may see clients who present with anxiety and other issues related to generational breakdowns such as feeling overlooked, alienated or misunderstood.

There is potential for resentment to form when younger generations don’t follow “the old-school method of working hard and waiting to earn your promotion” that older workers may expect, Key explains. However, career planning and goal setting for younger generations is unlikely to follow the steady, stable and gradual trajectory toward retirement that older generations came to expect. Instead, they may change jobs and careers several times to fit their family and life choices.

“We’re not a one-career society anymore. Making room for other things is OK,” Key says. “It’s essential for counselors to know about these aspects to identify and treat the issue. … Meet [clients] where they are. Understand what is happening. Be open and tell them that this is a very far-reaching thing, a pervasive issue that can affect people both at work and at home. It’s a very real issue, and we have to work with them to find what our clients need.”

“This is all so complex and vast that people may not even realize they’re affected by it. Let them know that they’re not alone and that many people are going through this,” Key adds. “Address it, and recognize that we [counselors] have the tools to be peacemakers.”

Greer, an adjunct professor at Texas A&M University-Central Texas, says she talks about workplace issues in her introduction to family counseling classes. Just as there’s no one definition of “family” anymore, she tells her students, there’s also no one definition of “work.”

“There’s no more going to work and punching a clock for 40 hours. Now, maybe you work from home or do Skype meetings late at night with other time zones. The world has become so different,” Greer says. “We’re in this whole uncharted place. It’s not so simple anymore.”

 

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Related reading

On helping clients with workplace stress and conflict, from the Counseling Today archives:

 

ACA Divisions

  • The National Career Development Association (ncda.org)

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

The ‘storm and stress’ of adolescence and young adulthood

By Laurie Meyers October 25, 2018

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For much of human history, the idea of adolescence being a distinct life stage was nonexistent. True, in the Middle Ages, children were recognized not merely as “mini” adults but as distinct beings with different needs. However, the years from ages 13 to 19 were not considered part of childhood until the turn of the 19th century. Instead, the “teen years” were the time when one began to assume adult responsibilities such as making a living and starting a family.

During the late 1800s, changes in child labor laws and the push for universal education for those under the age of 16 began to influence society’s perspective on when adulthood began. G. Stanley Hall, the first president of the American Psychological Association (APA), is credited with the modern “discovery” of adolescence, defining it in a 1904 book as a new developmental stage — created by societal changes — in which children grow into adults. Hall described adolescence as a time of “storm and stress” and, unlike later researchers, ascribed this life stage as lasting from ages 14-24 (rather than today’s generally accepted range of 13-19).

Although adolescence is still considered to be synonymous with the teen years, Hall’s instinct to single out the early 20s as different from later “adult” years was prescient. In the past decade, neurological research has discovered that the brain does not fully mature until one’s mid-to-late 20s. This revelation has spurred many researchers, particularly in mental health fields, to call for a separate developmental stage that is generally referred to as “young” or “emerging” adulthood.

Adding more than a soupçon of complication to both the recognition of emerging adulthood and the established research on adolescence is the reality that being a teen or 20-something in the information age is, in many ways, significantly different — and arguably more difficult — than it was for previous generations.

Stressed and depressed

An abundance of research indicates that teens and young adults are experiencing increased levels of stress and depression. In recent years, APA’s annual “Stress in America” survey has gathered data only on adults. However, in the survey released in 2014, “Stress in America: Are Teens Adopting Adults’ Stress Habits?” young people ages 13-17 were also included.

Survey respondents reported that during the school year, they had a stress level of 5.8 on a 10-point scale. During the summer break, teens reported a slight decrease in stress levels — 4.6 on a 10-point scale. Furthermore, 31 percent of survey respondents said that their stress levels had increased over the past year. In response to their high levels of stress, 40 percent of respondents reported feeling irritable or angry, 36 percent reported feeling nervous or anxious, 36 percent reported feeling fatigued or tired, and 31 percent reported feeling overwhelmed.

Depression is another significant concern among adolescents. According to the National Institute of Mental Health, in 2016 (the most recent year for which statistics are available), an estimated 3.1 million adolescents ages 12-17 experienced at least one major depressive episode. That number represented 12.8 percent of the U.S. population in that age bracket.

Although most mental health surveys do not specifically target “young” or developing adults, data are available relating to college students. Among the more than 31,000 college students who completed the 2017 American College Health Association National College Health Assessment, 39.3 percent reported being so depressed that they found it hard to function at some point during the previous 12 months. Anxiety levels among respondents were even higher: 60.9 percent reported feeling overwhelming anxiety at some point during the prior year.

The high levels of anxiety and depression indicated in these studies are part of a national pattern of significantly increasing distress. A national poll published in May by the American Psychiatric Association noted a sharp increase in American anxiety levels over the past year. On a scale of 0-100, this year’s “national anxiety score” was a 51 — a five-point jump since 2017. A study published in the June 2018 issue of the journal Psychological Medicine found that rates of depression rose across all age brackets of Americans for those 12 and over from 2005 to 2015. Most significantly, among those ages 12-17, depression rates increased from 8.7 percent in 2005 to 12.7 percent in 2015.

Under pressure

Some researchers are eager to blame technology — particularly social media — for the increase of depression and anxiety among teenagers and young adults. The reality is more complex and involves myriad factors.

It is undeniable that some people do find their lives lacking when compared with what they see on social media. Carefully curated Facebook feeds can suggest to them that their friends are happier and more successful than they are. Celebrity photos on Instagram — most of which are professionally produced and heavily filtered — can encourage unrealistic expectations about body image and personal appearance. However, when one considers the role that social media plays in the quest for perfection, it may be something of a chicken-and-egg scenario.

A 2017 study on perfectionism that appeared in the journal Psychological Bulletin found that beginning in the 1980s, a culture of “competitive individualism” in the United States, Canada and the United Kingdom steadily increased the quest for personal perfection. So, is what we see on social media pushing us toward unattainable standards of perfection, or is it a reflection of the pressure we put on ourselves? At this point in time, we may be caught in a reinforcing loop. The study found that current generations not only feel intense societal pressure to be perfect but also expect perfection from themselves and others. The study’s authors also believe that this rise in perfectionism may be linked to an increase in myriad psychological problems.

Today’s teenagers and young adults are unquestionably subject to high expectations and demands. Licensed mental health counselor David Flack, who has worked with adolescents and young adults for 20 years, says he has seen a significant increase in anxiety related to academic performance among his clients.

“It is not uncommon for teens I meet with to have three, four or even more hours of homework most days,” he says. This reality creates significant pressure and is particularly stressful for students who are predisposed to anxiety. Flack, a member of the American Counseling Association, also believes that such heavy academic workloads are interfering with important social and developmental processes because many teenagers may be spending more time doing homework than socializing and engaging in extracurricular or other age-appropriate activities.

Licensed professional counselor (LPC) Sean Roberts, an ACA member who specializes in working with young adults, says he has witnessed a precipitous increase in anxiety among clients. He thinks this is strongly, though not solely, linked to teenagers and young adults feeling increased pressure to succeed.

Not coincidentally, the anxiety they experience makes it only more difficult for them to achieve. “Anxiety has a neurological effect,” explains ACA member Amy Gaesser, an assistant professor of counselor education at the State University of New York at Brockport whose research focuses on the social and emotional well-being of students in school. “The survival part of the brain activates and shuts off or interferes with the parts of the brain that help us think clearly.”

This can have a significant effect on academic performance, says Gaesser, a certified school counselor in New York who gives presentations and offers private consultations with parents. For example, some students can study extensively and be fully prepared for a test, but because of their anxiety, can have trouble accessing that information while taking the test. Anxiety can also interfere with the ability to take in and synthesize information, Gaesser says. Students become frustrated with their seeming inability to “get it,” which affects their feelings of self-efficacy and can even make them question their level of intelligence. Once a pattern of academic difficulty tied to anxiety is established, the problem can become self-perpetuating.

Disrupting the cycle is vital, says Gaesser, who recommends the emotional freedom technique (EFT) as an effective method of interrupting the stress response and downregulating the brain. In EFT, participants respond to stressful thoughts or situations by visualizing an alternative outcome while taking their hands and tapping acupuncture points on the body that have been linked to stress reduction. Students can go through the whole sequence of body points or just use the areas they find work best for them, she says.

Gaesser also recommends the “4-7-8” breathing method as a quick way to interrupt the stress response. This involves breathing in for four seconds, holding the breath for seven seconds and then breathing out for eight seconds. Students can practice this method themselves, but Gaesser thinks that teachers should also use it in their classrooms as a way to begin class.

Peter Allen, an LPC based in Oregon who specializes in counseling young adults and adolescents, used to work with teenagers in a wilderness therapy setting. Most of his clients were struggling with a variety of issues, including substance abuse, conduct problems (although not usually at the conduct disorder level) and mood disorders, principally depression and anxiety. In most cases, Allen says, the core elements of the wilderness setting were effective in helping these clients address their various presenting issues.

In part, he believes that’s because the pressures of school, family and social life were stripped away, leaving these teenage clients to focus on the basics, such as securing food and shelter. Surviving in the wilderness also required working together and building a community, which helped teach clients new communication skills. Participants also got daily exercise, ate healthy meals and were required to follow a regular sleep schedule, all of which had a calming and stabilizing effect. “Once diet, sleep and exercise have been regulated, about half of the problems disappear right away,” Allen says.

Many wilderness therapy clients also benefit from what Allen calls “expanding the size of their world. … If you are a 15-year-old kid and doing bad at school, arguing with your parents, your world is tiny.” The wilderness program not only provided literal wide-open spaces, but also introduced clients to people from different places and adults who didn’t have the same expectations as the teenagers’ parents or teachers did.

The wilderness can also serve as a mirror for clients, says Roberts, who has also worked in wilderness therapy, or, as he says it is becoming more commonly known, outdoor behavioral health care. For instance, when clients who struggle with executive function and organization encounter bad weather for which they are not prepared, the experience can be a vivid demonstration of the importance of working on those problem areas. Another example: Someone who is struggling with distress tolerance will need to get used to having to build a fire after hiking all day.

Information overload?

Although none of the counselors interviewed for this article view social media or technology as inherently negative, they agree that living in the information age is complicated. The current generation of teens and young adults is awash in an unprecedented flood of information, asserts Roberts, clinical director at Cascade Crest Transitions, a program that provides support to young adults struggling to launch their independence by attending college or obtaining a job. He maintains that this technological bombardment not only is difficult to assimilate but also can encourage the tendency to “get stuck” in one’s own head.

Allen adds that in the age of the internet, children and adolescents are exposed to a lot of information and knowledge at an earlier age than previous generations were. In certain cases, it is information that they may not have the maturity to handle. For example, most children and adolescents who grew up in the latter half of the 20th century had to somehow get their hands on a copy of Playboy or another adult magazine to satisfy their sexual curiosity. Today’s children and teens are exposed online to myriad genres of easy-to-access pornography, which not only present unrealistic ideals of sexuality but also can include disturbing practices such as bestiality and pedophilia. Children and young adolescents today are also more likely to be exposed to media coverage of frightening or horrific events before they have the ability to contextualize all that they are taking in, Allen says. He believes this early exposure is contributing to a kind of “nonspecific existential dread” that he says he commonly sees in his clients.

Roberts says that technology offers many positive benefits, but it also sometimes provides adolescents and young adults with a means to avoid their problems. He stresses the need for counselors to learn more about the draw of technology so that they can help clients evaluate whether they are using it in positive or negative ways. Roberts gives gaming as an example. For those who know little about it, gaming may seem like an excuse to “do nothing.” In reality, he says, it is a legitimate hobby that can provide enjoyment, stress release and even a sense of community while boosting problem-solving skills. However, like any other activity, when gaming gets in the way of schoolwork, chores or getting out of the house, it becomes a problem to be addressed, he says.

Another complicated aspect of online life is social media. For all the potential benefits, social media feeds have made it so that virtually no part of life is private anymore, Allen says. Many adolescents may not fully understand that by making everything public, the internet is, in essence, “forever” or grasp the potential ramifications of that reality, he says. In addition, he notes, social media feeds can encourage social contagion.

ACA member Amanda LaGuardia, a former private practitioner whose research focuses on self-harm, agrees. Much of the social media content targeted to young girls is focused on body image, says LaGuardia, a licensed professional counselor supervisor in Texas and a licensed professional clinical counselor supervisor in Ohio. Many of her former clients talked about the images they saw on Instagram, such as already-thin celebrities discussing “thigh gap” (as part of a supposedly “perfect” body, women and girls must have thighs that don’t touch each other) and other unrealistic physical standards. Such posts are usually popular, garnering a large number of likes and admiring comments, which gives girls the impression that this is what their bodies should look like, she says.

However, such standards are unrealistic for most females and are simply unachievable for girls with developing bodies, continues LaGuardia, an assistant professor at the University of Cincinnati. Regardless, these images are presented as the feminine ideal, presuming to highlight all of the elements that will make women attractive to men. At the same time, girls are often subject to sexual harassment at school and too often told by those in authority “that’s just how boys are” (boys will be boys) and that girls just need to find a way to deal with it, she says.

All of these messages about how girls should look and act and what they should accept come at a time when they are already struggling to figure out who they are. It is overwhelming, and self-injury is becoming a more common way to cope with the distress. Self-harm used to be most common in the eating disorder population, but according to LaGuardia, social media has introduced it to a wider audience. It isn’t necessarily that self-injury is presented as a positive behavior online. Most people who talk about it on social media are seeking support, she says. However, the widespread nature of the discussion has created social contagion.

The best thing counselors can do to help is listen and affirm, LaGuardia emphasizes. When adolescents talk about their experiences, some counselors focus on helping them feel better about themselves, but that is not what they need most, she asserts. Instead, adolescents need to express what they are going through and to process their confusion verbally. Counselors should respond, she suggests, by saying things such as, “That sounds really difficult” and “I’m here and I’m listening.”

“So many of the messages they [adolescents] are receiving are controlling,” LaGuardia explains. “They need to feel in control.”

As these clients become more comfortable, they will begin to talk about how they are coping with their turmoil. LaGuardia explains that these clients view self-injury as a means of surviving what they are currently experiencing, not a solution. “I ask clients, ‘Is this something you see working for you for the rest of your life?’ I’ve never had anyone say yes.”

Usually, LaGuardia notes, clients will say that they hope not to engage in self-harm forever, but at the current time, they don’t know what else to do. At that point, counselors can ask whether this coping method is something the client is ready to change. LaGuardia says the first step is finding out what the client needs help coping with and then exploring ways that will allow the client to cope without self-harm.

The most common underlying problem for clients who self-harm is conflict with a parent or sibling, LaGuardia says. In such cases, she works with the whole family on communication skills. She starts with the adolescent clients, teaching them how to express their needs without self-injury. She asks the adolescents to think about their most stressful conflicts and what they would like their parents to know. Then, through role-play, LaGuardia helps these clients practice asking for what they need.

Often, LaGuardia will also bring in the parents and have the adolescent express the source of conflict. As the parents and adolescent talk, things can get heated, so LaGuardia is there to help redirect the conversation. She also tries to educate parents about what adolescents need, which includes being treated as independent young adults and given space to grow, while at the same time knowing that their parents are always there to listen to them regardless of
the circumstances.

Adult transitions

Allen is the program director at College Excel, a residential, coaching-based college support program. The program’s clients are typically young adults who are coming out of high school and looking for extra support to succeed in college or those who previously attended college but dropped out because of a mental health issue or learning disability.

Many of the students have some level of anxiety and depression and often struggle with executive function deficits. College Excel provides the students with mental health support and coaching on life and study habits. Allen says he tries to run the program through the lens of good mental health practices. Calling on his background in wilderness therapy, he also encourages students to eat well, follow a consistent sleep schedule and get regular exercise. College Excel staff do not live on-site, but the program does provide students with housing, which helps them establish a sense of community and support — elements that are common among those who successfully adjust to college life, Allen points out.

Allen says that many of the program’s clients struggle with attention-deficit disorder and organization. College Excel staff teach students basic organizational skills such as using their attention strategically. For example, with students who struggle with memory and retaining information, Google Calendar can be a particularly useful tool. It can tell students where they need to be at any given moment, freeing up their attention and memory for other tasks.

Allen also talks with students about the importance of a clean workspace and provides them with practical tips on organization. For example, he says, students who constantly misplace things can save time and frustration by designating a space for pens, papers and other basics so that they will always know where to find them.

Students also work on developing good study habits. For example, rather than growing frustrated with their struggles to focus on what they’re reading for long periods of time, clients learn to study in 15- to 20-minute chunks, with five-minute breaks in between.

Roberts’ program is geared toward young adults who are coming from inpatient treatment and are ready to enter college or find a job. In addition to receiving ongoing mental health treatment, these clients take classes that focus on interpersonal skills, stress regulation, goal setting, time management and money management. They are also encouraged to exercise, and all students are matched with a case manager who helps them focus on sleep hygiene, peer interaction, health and nutrition, and, in some cases, dating.

Clients are required to attend one individual and one group counseling session per week. Counselors are also on-site five days a week, which allows them to give feedback outside of sessions. For example, a counselor might say to a student, “You say that you want to socialize, but you’re constantly retreating to your room or on the phone.” This opens up a discussion about why the student isn’t following through on counseling goals and allows the counselor and client to work on solutions together, Roberts says.

The students are usually enrolled in college or working when they start Roberts’ program. The coaching and classes take place around the students’ schedules, and staff members are available to help clients through whatever challenges they are facing in school or at work. Clients typically remain in the program about nine to 12 months. During the last six months, they move out of program housing and into their own apartments or college dorms.

Allen closes by noting that today’s adolescents and young adults — the oft-discussed millennials — are very much aware that older generations generally view them in a negative light. He believes this widespread maligning carries a psychic weight for this generation and can contribute to limiting their self-efficacy and sense of options.

Because this negative image of adolescents and young adults is so prevalent, Allen believes that even counselors may fall prey to it. “You can’t hold them in contempt and do good work,” he emphasizes. “The best thing we could be doing for them is stoking the fire of creativity.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • Youth at Risk, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
  • Active Interventions for Kids and Teens, by Jeffrey S. Ashby, Terry Kottman and Don DeGraaf
  • Suicide Assessment and Prevention, DVD, presented by John S. Westefeld

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Suicide Prevention
  • Substance Use Disorders and Addiction
  • LGBTQ Resources

Webinars

  • “Depression/Bipolar” with Carmen S. Gill (CPA22120)
  • “Trauma/OCD/Anxiety” with Victoria E. Kress (CPA22118)
  • “Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl (CPA22116)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Voice of Experience: Losing a client

By Gregory K. Moffatt October 22, 2018

1 Comment

My colleague sat across from me, teary-eyed, in the conference room where we had met so many times before while she was under my supervision. Now, only a few months into her new life as a fully licensed clinician, she had lost a client to suicide. She was understandably distraught.

The client was high risk from the beginning, but my colleague hadn’t missed anything. She had covered every base she could. She had developed a thorough safety contract with the client that included an emergency plan, coping skills for the client to use and an emergency contact person for the client. The last time my colleague had seen her client, he had appeared slightly improved. He had assured her that he would attend to the safety contract and would be back the following week for his appointment. Sadly, he took his own life two days later. Perhaps his perceived improvement was simply resolve to follow through with a suicide. We will never know.

I have never lost a client under my care to suicide, but I suppose that even now, in the twilight of my career, such a loss would be devastating to my heart and my esteem. My young colleague was just beginning to gain some confidence in her clinical skills. Approval from the licensing board had helped nudge her professional esteem into a reasonably healthy place — only to have this happen.

The tragic loss of a human being and the lifetime of pain such an act brings to family members is our primary concern, of course. But we counselors have to manage such tragedies too.

What did I miss? If only I’d hospitalized! Maybe more frequent sessions would have been better. These are among the obsessive thoughts that plagued my friend and brought her to tears that day in my conference room.

But the fact is, we cannot control the private lives of any of our clients. Some will be success stories, and others will not. All we can do as counselors is to guide them. A client’s life is their own.

When I began my career, I had a client who was having an affair but wanted to get his marriage back in order. Obviously, to reach that goal, the affair needed to end. But he chose to continue the affair, no matter how many times he acknowledged the damage it was doing to his family. The outcome was inevitable. Predictably, he and his wife eventually divorced.

Perhaps a better therapist could have helped him succeed in achieving his stated goal, but even in hindsight, I think not. He was determined to do what he wanted to do, and there was little I could do to stop him.

In a similar manner, I helped my colleague to see that even her client’s wife — someone who was with him most of every day, someone who slept in the same bed with him — couldn’t stop him from harming himself. He had been determined.

Saying “the client chooses” doesn’t remove responsibility from us as counselors. Therefore, she and I reviewed her procedures with the client to ensure that she hadn’t missed something. She had not. I suspect that even hospitalization wouldn’t have kept her client from eventually taking action.

Our clients will make their own choices. Sometimes they will relapse into addictions, return to abusive relationships and, yes, if you are in the field long enough and work with high-risk clients, some will even take their own lives.

Although we must have compassion for our clients, we must also develop something I call “disinterestedness.” This simply means that we must remain apart from the choices our clients make. We are “disinterested” in the sense that we won’t thrust our ideals upon them. Being compassionate usually comes naturally for counselors. That is why most of us pursue this career. Practicing disinterestedness, on the other hand, is difficult, but it is equally important.

Coping with this loss won’t be easy, but my friend is putting it behind her. So to you, my colleagues, I encourage you to remember disinterestedness in your practice, especially when your clients move in a hazardous direction. You cannot control them, and even if you could, that would overstep our ethical boundaries.

Yes, it is necessary for us to review such cases. If errors were made, put systems in place so that you won’t make the same errors again. But then move forward and do your job. Your clients’ decisions aren’t about you.

 

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Gregory K. Moffatt is a veteran counselor of more than 30 years. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at Greg.Moffatt@point.edu.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Helping clients with post-date anxiety

By Kathleen Smith October 15, 2018

1 Comment

As a counselor, I have a front-row seat for watching anxiety develop in new relationships. It is truly fascinating to observe how quickly two people can become emotionally stuck together. A therapy client will leave for a week and return reporting that he or she has started dating someone new. This former stranger now has the power to make my client very happy or very anxious. Thanks to their phone, my client might spend all day analyzing a text they received — or worrying about the lack of one.

Not a week goes by without me having multiple conversations with people about texting in relationships. For instance, a person is seeing someone who doesn’t quite contact them as frequently as they would like, so their brain sounds the rejection alarm. When the other person finally does text them, their anxiety level goes down. But within a day or two, they need more reassurance. They’ve surrendered their capacity to calm down to someone who was a stranger to them a week ago. And the only way they know how to get that capacity back is to end the relationship.

I don’t think that texting causes emotional dependence, but it can certainly accelerate it and reinforce it. People used to have to wait much longer to hear from a prospective romantic partner. Now people want to hit the eject button if there’s been radio silence for 24 hours. There is an expectation that someone who is interested in us must also be available to us at all times. We are in such a hurry to lock things down as a way of managing our own anxiety and insecurity.

I’m in no position to throw a stone here. After my husband and I went on our first date, he waited five days to ask me out again. Five. Days. For millennials, five days is the equivalent of somebody going off to war and coming back home. Now, of course, I know that he was a mature human being who was simply living his life at that time. But if you retrieved my phone records from that week, I bet you would see a blizzard of worried texts to friends.

When our counseling clients become more anxious in a new relationship, they don’t suddenly become more insightful. They usually just double down on whatever they’ve already been doing. That usually means anxiously focusing even more on this new person. They might stalk them on social media, or stare at their phone trying to decipher old texts. They’ll talk to all their friends about whether they should dump this person for taking so long to reply. They’ll come to a counseling session and ask me to guess what this person — whom I have never met coincidentally — is thinking.

When we feel the potential to be hurt, it makes sense that we focus more on the threat and how to avoid it. This works great if a lion is chasing us. It’s not so great for being in a relationship.

People see a lot of lions when they date, simply because dating is such an anxious endeavor. They interpret a lack of constant contact in a new partner as a sign of flakiness, disinterest or duplicity. People don’t stop to consider whether less contact might be a potential sign of maturity. This is why people tend to end up with other people who are at the same level of emotional maturity as themselves. People who have a higher degree of maturity in their family relationships are likely to seek out a partner who wants the same amount of contact.

I would never say to a someone, “Have you considered that this person is not texting you as much because they’re more mature?” Because that would be a guess based on zero facts. What I do challenge people to do, however, is to see their part in the relationship. Often, if people can stay focused on being the person they want to be rather than on trying to control this new love interest of theirs, then their anxiety will go down. And most of the time, people do not want to be the kind of person who is glued to their phone 24/7.

So, the goal isn’t for clients to change their new crush or to teach the person how to text that Goldilocks (just right) amount. The goal is to lower clients’ anxiety enough to where they can actually think objectively and decide whether a relationship is right. That decision is impossible to make when anxiety is very high, because then we interpret even the smallest behavior as a threat. People will blow up a relationship quickly in order to lower their anxiety.

Anxiety isn’t just present in romantic relationships, of course. We all want people to like us, reassure us and agree with us, but we ultimately can’t control them. People in our lives are not always going to respond as quickly as we would like. They’re not always going to RSVP to the party or share our level of enthusiasm for a television show. If clients can see how the anxiety they feel is a possible sign of emotional interdependence, they might be less likely to act immaturely or irrationally in their relationships. The rejections or silences won’t feel so threatening, and they won’t have to cancel that party out of spite or send a passive-aggressive message.

The simple truth is that we enjoy relationships more when we aren’t as anxiously focused on them. By being more of an individual, we can actually get closer to the people we love. Who doesn’t want that?

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. Read more of her writing at kathleensmith.net.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.